The School of Nursing & Midwifery by HC12022423431

VIEWS: 31 PAGES: 18

									                                  The School of Nursing & Midwifery
                                  Application Form for admission to
                         BSc (Hons) in Midwifery Studies 2012-2013
PLEASE COMPLETE IN BLOCK CAPITALS (TYPEWRITTEN OR IN BLACK INK) AND IN CONJUNCTION WITH
                          THE ACCOMPANYING GUIDANCE NOTES.

            Closing date for receipt of completed applications is 4pm on Friday 6th January 2012
   Please note it is your responsibility to ensure that the application form is received by this date and time.

1. PERSONAL DETAILS
Surname                                              First names (in full -as shown on Birth Certificate)

Title Mr/Mrs/Miss/Ms                                 All Previous Surname(s)

Date of Birth                                                    Correspondence Address

Country and Place of Birth

National Insurance Number

Civil / Marital Status

Occupation                                                       Postal Code

Nationality                                                      Date of first entry to the UK (if appropriate):

Country of Domicile                                              Next of Kin Details

Contact Telephone Numbers                                        Name, Address and Telephone Number:

Home:

Mobile:

Email:

If you are, or have ever been, a student of this or any other University, please state:
(1) Your first year of entry                                (2) Your student number
Do you have a disability? Yes/No

If yes, what is the nature of your disability?


Occupational Background
If you are in full-time education, please state the occupation of the highest earning family member of the household in which
you live. If he or she is retired or unemployed, give their most recent occupation. If you are not in full-time education,
please state just your own occupation.



Office Use Only                            Decision and Conditions.
REC’d                                                                                                                Initials
QSIS
OFFER




                                                                                                                          1
Availability for Interview

All shortlisted applicants to the BSc (Hons) in Midwifery Studies programme will be
interviewed, usually by a joint panel of academic staff and clinicians. It is anticipated that
interviews will take place in March 2012. Shortlisted applicants will be advised of a specific
date in writing by the School of Nursing and Midwifery.

Shortlisted applicants, who are called to interview, will be expected to speak knowledgeably
about 2-3 current health or social care issues and what those issues might mean for the
health sector or patients.

Please specify any dates in March 2012 when you will not be available to attend for interview.

I will not be available to attend for interview on the following dates:

From                                         To




Please note that whilst the School of Nursing and Midwifery will endeavour to take account of your availability, it
is under no obligation to do so.




                                                                                                                  2
2. INSTITUTES ATTENDED

Name of ALL Institutes attended       Address                                            From         To
(to include all
Schools/Colleges/Universities)




3. EDUCATIONAL QUALIFICATIONS
Please give details of ALL School leaving/College/University examination results listed in full.
You must be able to produce valid certification for ALL qualifications listed below.
Type of Examination     Date Taken   Subject                                Level       Result/        Office
(eg GCSE, etc)                                                                          Grade          use
                                                                                        Obtained       only




Please give details of ALL PENDING examination results.
You must be able to produce valid certification for ALL qualifications listed below, before a final offer
can be made by the School of Nursing and Midwifery.
Pending Results      Date Results Due     Subject                           Level              Predicted
(type of                                                                                         Grade
examination)




4. PROFESSIONAL QUALIFICATIONS (NURSING)
Professional Qualification     Part of         Name of Educational Institution and/or              Date of
                               Register        Professional Body                                   Award/Entry




                                                                                                                3
Date of Registration with NMC                  PIN NO                    EXPIRY DATE

Have you previously commenced Midwifery Training?                           Yes                     No
If ‘YES’, you are required to give details of where and when you undertook this programme and your reasons for
leaving. You are also required to provide an official transcript of training from the institute attended




5. EMPLOYMENT HISTORY
PROFESSIONAL EXPERIENCE
Please give details of posts held since registration commencing with present/most recent post.
Place of Employment              Type of Ward or      No./Name of Ward    Post Held         Duration of
                                 Dept                                                       Employment
                                                                                            From      To




If you are currently in employment, please state the minimum period of
notice required by your employer:

OTHER EMPLOYMENT EXPERIENCE (including vacation and/or voluntary work)
Please specify exact dates and ensure that you cover all periods of employment and unemployment with no
gaps.
Name and Address of           Post Held and Brief              Dates of Employment     Reason for Leaving
Employer                      Description of the Nature of
                              Employment
                                                               From        To




Please note that if you have previously worked in the Health & Social Services area, you will be
required to give details of any current or previous disciplinary action that has been taken against you.

                                                                                                             4
6. REFEREES
Please give names and addresses of two referees from whom references may be obtained. These must NOT be
relatives, friends or neighbours. Your first referee MUST be able to provide an academic reference (e.g. College
Director or University Head of Department). The second referee MUST be your most recent employer.
Your Referees MUST complete the attached reference forms (see Guidance Notes).

Please note that it is YOUR RESPONSIBILITY to ensure that references are received by the School of Nursing
and Midwifery. Failure to do so may result in your application being rejected.

1. Name                               Position                              Tel No.

Address




                                                             Postcode
Capacity in which applicant is known to the referee



2. Name                               Position                              Tel No

Address




                                                             Postcode
Capacity in which you are known to the referee:




                                                                                                               5
7. ADDITIONAL INFORMATION/PERSONAL STATEMENT (MAX 300 WORDS)
Please give any further information which is relevant to your application, in particular your reasons for wishing
to join the programme, what benefits you expect to gain and the attributes and abilities you have relevant to the
programme for which you are applying, also please give brief details of your spare time activities and any
membership of clubs and societies. You must use only the space provided below. Do not submit extra sheets.




                                                                                                                6
8. DECLARATION AND SIGNATURE OF APPLICANT
   By completing this Declaration, applicants are agreeing that they have read, understood and
   agree with the commitment statements.

   Please read the Commitment Statements below and indicate that you agree with each of the
   statements by ticking each box.

   I confirm that the information given on this form is true, complete and accurate. I have read and complied
   with the guidance notes for completing the application form and I accept that if the relevant information is
   inaccurate or omitted, the University reserves the right to reject my application.

   I authorise the University to approach Government Agencies, Educational Establishments, Former
   Employers and Referees for verification of application details and I consent to the University processing the
   information in this form for administrative and research purposes, including consideration of my
   application, in accordance with the provisions of the Data Protection Legislation.

   I understand that the University works in partnership with the Health and Social Care Trusts and other
   healthcare providers to facilitate Practice Placements. I consent to my details being shared with these
   providers.

   I understand that the University has placement providers throughout Northern Ireland and therefore
   requires Midwifery students to be on placement in many different locations.

   I understand that Midwifery operates 24 hours a day, 365 days a year and therefore requires a student to
   undertake shifts and to be on duty during seasonal holiday periods and bank holidays whilst on practice
   placement.

   I understand that Midwifery students are expected to wear a uniform at all times whilst on duty in order to
   present an appropriate image to the public.

   I understand that the University expects students to act professionally both on and off duty at all times, and
   that I will be expected to maintain the highest standards of conduct and integrity at all times.


SIGNATURE:__________________________________________ DATE:____________________________________

YOU SHOULD RETURN THE COMPLETED                 Registry Department
APPLICATION FORM TO:                            The School of Nursing and Midwifery
                                                The Queen’s University of Belfast
                                                Medical Biology Centre
                                                97 Lisburn Road
                                                Belfast BT9 7BL


Closing date for receipt of completed applications is 4pm on Friday 6th January 2012.
Please note it is your responsibility to ensure that the application form is received by this date and
time.




                                                                                                                    7
APPENDIX 1: CRIMINAL RECORDS CHECK
Please Note: THIS FORM ASKS YOU TO GIVE WRITTEN CONSENT TO THE ACCESS NI ENHANCED
DISCLOSURE CHECK. YOU MUST COMPLETE AND RETURN THIS FORM WITH YOUR APPLICATION FORM
OTHERWISE YOUR APPLICATION TO THE PROGRAMME WILL BE REJECTED.

Please refer to Guidance note: Appendix 1

First Name:                                              Surname:

Date Of Birth:                                           Place of Birth:

Address:                                                 National Insurance Number:



DO YOU CONSENT TO A CRIMINAL RECORDS CHECK?                 (please tick) YES            NO     

DO YOU HAVE A CRIMINAL RECORD?                              (please tick) YES            NO     

If YES, please list below details from your complete criminal record, including all prosecutions pending and any
professional investigations as detailed above. Give as much detail as you can, including, if possible, the
offence, the approximate date of the court hearing and the court which dealt with the matter. You may continue
on a separate sheet and attach it to your application, providing you sign and date it.

Please note that you must also inform the School of Nursing and Midwifery if you are currently, or have ever
been, subject to an investigation and/or disciplinary proceeding by a healthcare-related employer, agency or
regulatory body, irrespective of the outcome.

PLEASE NOTE THAT YOUR APPLICATION MAY BE REJECTED IF YOU FAIL TO DISCLOSE SOME OR ALL OF
YOUR CRIMINAL RECORD.




I understand that a criminal records check must be carried out by the School of Nursing and Midwifery before
my selection can be confirmed and I am aware that my full criminal record, including spent cautions and
convictions and current police investigations, will be disclosed. The need for my criminal record has been
explained and the information I have given above is accurate. I consent to the check being made and I
understand that non-declaration may result in my application being rejected.

You should note that Placement providers require confirmation of whether your criminal history check is clear
or not. In some situations they may require access to the specific detail on your Enhanced Disclosure
Certificate (criminal history check) before allowing you to commence your placement. To avoid any delay with
providing this information to your placement provider, and subsequently delaying the start of your placement,
your signature at this section will also indicate your consent for this information to be disclosed.

Please note that if you are made an offer by the School of Nursing and Midwifery to join the programme, you will
be required to make a payment of £30 for your Access NI Enhanced Disclosure Report. Futher information on
how to make this payment will be contained in your Letter of Offer.


SIGNATURE:                                                             DATE:

                                                                                                               8
                           BSc (Hons) DEGREE IN MIDWIFERY STUDIES


APPENDIX 2: REFERENCE FORM                                                                CONFIDENTIAL
PLEASE COMPLETE IN BLOCK CAPITALS (TYPEWRITTEN OR IN BLACK INK)

TO BE COMPLETED BY APPLICANT – Please see Guidance Notes overleaf.
Applicant’s Name

Applicant’s
Correspondence
Address


TO BE COMPLETED BY REFEREE 1 – Please see Guidance Notes overleaf.
Referee’s Name             Referee’s Telephone Number


Referee’s Address                 Referee’s Occupation and capacity in which the applicant is known to you.




Reference




Do you know of any reason why the applicant would not be suitable to undertake this Midwifery programme?
YES       NO 

If Yes please give reasons (continue on separate sheet if necessary)




HEALTH
Please state the number of days absent in the past 2 years.

How many periods of absence due to illness has the applicant had in the past 2 years?

SIGNATURE OF REFEREE:                                                  DATE:



                                                                                                           9
APPENDIX 2: REFERENCE - GUIDANCE NOTES

TO THE APPLICANT

        Please detach this section from your application form, to be completed by the person named on the
         application form as your referee (Section 7), and who has agreed to provide a reference.

        Your referee must not be a relative, friend or neighbour.

        Please insert your name and correspondence address in full in the space provided and forward the
         Reference Form to your referee for completion.

        Please ensure that your referee returns the completed reference to the School of Nursing and
         Midwifery by the closing date, 4pm on Friday 6th January 2012.

Please note that it is YOUR RESPONSIBILITY to ensure that references are received by the School of Nursing
and Midwifery.

TO THE REFEREE

The person who has approached you for a reference is applying to undertake a BSc (Hons) Degree in
Midwifery Studies at Queen’s University Belfast. The Midwifery programme aims to prepare students to work
in the Midwifery profession in both hospital and community settings.

One of the most important factors in determining whether an applicant is subsequently offered a place is the
confidential statement made by referees.

The reference you provide will be scrutinised at each stage of the application process. You are therefore
asked to state your opinion of the applicant’s qualities and fitness for admission to the course. This should
include their general health and attendance record over the past two years. This information is important in
order for the University to ensure that applicants are sufficiently healthy to meet the demands of the
Midwifery programme. It is also important to outline any reason why you consider the applicant may not be
suitable for this programme.

To ensure fairness to all applicants, you are asked to provide information on the topics in the list below.

1. Communication/Interpersonal Skills                         6. Health and attendance record in the past two
2. Initiative, Motivation/Commitment                             years of employment, College/University or in
3. Confidence                                                    the capacity known to you
4. Potential to follow a personally and                       7. Ability to use own initiative and work as part of
   academically challenging education programme                  a team
  including predicted results or performance.
5. Reliability


It would be useful if you would please:
     check that the applicant has printed his/her name in the space provided on the form;
     complete your reference in block capitals on the sheet provided (typewritten or in black ink);
     send the original copy of your reference, signed and dated, to the School of Nursing and Midwifery at
        the address below.

Please return the reference to:
The Registry Office
School of Nursing and Midwifery
Queen’s University Belfast
Medical Biology Centre
97 Lisburn Road
BELFAST
BT9 7BL
Tel: 028 9097 5718 / 5719




                                                                                                                10
                           BSc (Hons) DEGREE IN MIDWIFERY STUDIES


APPENDIX 2: REFERENCE FORM                                                                CONFIDENTIAL
PLEASE COMPLETE IN BLOCK CAPITALS (TYPEWRITTEN OR IN BLACK INK)

TO BE COMPLETED BY APPLICANT – Please see Guidance Notes overleaf.
Applicant’s Name

Applicant’s
Correspondence
Address


TO BE COMPLETED BY REFEREE 2 – Please see Guidance Notes overleaf.
Referee’s Name             Referee’s Telephone Number


Referee’s Address                 Referee’s Occupation and capacity in which the applicant is known to you.




Reference




Do you know of any reason why the applicant would not be suitable to undertake this Midwifery programme?
YES       NO 

If Yes please give reasons (continue on separate sheet if necessary)




HEALTH
Please state the number of days absent in the past 2 years.

How many periods of absence due to illness has the applicant had in the past 2 years?

SIGNATURE OF REFEREE:                                                  DATE:



                                                                                                         11
APPENDIX 2: REFERENCE - GUIDANCE NOTES

TO THE APPLICANT

        Please detach this section from your application form, to be completed by the person named on the
         application form as your referee (Section 7), and who has agreed to provide a reference.

        Your referee must not be a relative, friend or neighbour.

        Please insert your name and correspondence address in full in the space provided and forward the
         Reference Form to your referee for completion.

        Please ensure that your referee returns the completed reference to the School of Nursing and
         Midwifery by the closing date, 4pm on Friday 6th January 2012.

Please note that it is YOUR RESPONSIBILITY to ensure that references are received by the School of Nursing
and Midwifery.

TO THE REFEREE

The person who has approached you for a reference is applying to undertake a BSc (Hons) Degree in
Midwifery Studies at Queen’s University Belfast. The Midwifery programme aims to prepare students to work
in the Midwifery profession in both hospital and community settings.

One of the most important factors in determining whether an applicant is subsequently offered a place is the
confidential statement made by referees.

The reference you provide will be scrutinised at each stage of the application process. You are therefore
asked to state your opinion of the applicant’s qualities and fitness for admission to the course. This should
include their general health and attendance record over the past two years. This information is important in
order for the University to ensure that applicants are sufficiently healthy to meet the demands of the
Midwifery programme. It is also important to outline any reason why you consider the applicant may not be
suitable for this programme.

To ensure fairness to all applicants, you are asked to provide information on the topics in the list below.

1. Communication/Interpersonal Skills                         6. Health and attendance record in the past two
2. Initiative, Motivation/Commitment                             years of employment, College/University or in
3. Confidence                                                    the capacity known to you
4. Potential to follow a personally and                       7. Ability to use own initiative and work as part of
   academically challenging education programme                  a team
  including predicted results or performance.
5. Reliability


It would be useful if you would please:
     check that the applicant has printed his/her name in the space provided on the form;
     complete your reference in block capitals on the sheet provided (typewritten or in black ink);
     send the original copy of your reference, signed and dated, to the School of Nursing and Midwifery at
        the address below.

Please return the reference to:
The Registry Office
School of Nursing and Midwifery
Queen’s University Belfast
Medical Biology Centre
97 Lisburn Road
BELFAST
BT9 7BL
Tel: 028 9097 5718 / 5719




                                                                                                                12
APPENDIX 3: CLINICAL AREA

                      BSC (Hons) MIDWIFERY STUDIES 2012-2013



    Applicant’s Name _________________________________________

    Please state your first and second preference (if you have one) for the Clinical
    Area in which you wish to gain the major part of your clinical experience.
    The University reserves the right to make the final allocation dependant on
    availability of suitable placements.


           BELFAST HEALTH & SOCIAL CARE TRUST

                 Royal Jubilee Maternity Service

                 Mater Hospital


           SOUTH EASTERN HEALTH & SOCIAL CARE TRUST

                 Ulster Hospital/Lagan Valley Hospital/Down Hospital

           NORTHERN HEALTH & SOCIAL CARE TRUST

                 Antrim Area Hospital

                 Causeway Hospital

           SOUTHERN HEALTH & SOCIAL CARE TRUST


                 Craigavon Area Hospital

                 Daisy Hill Hospital


           WESTERN HEALTH & SOCIAL CARE TRUST

                 Altnagelvin Hospital

                 Erne Hospital




                                                                                       13
         GUIDANCE NOTES FOR COMPLETING THE APPLICATION FORM
   FOR ADMISSION TO BSc (Hons) DEGREE IN MIDWIFERY STUDIES 2012-2013


                                       IMPORTANT

                                For Entry in November 2012



These guidance notes contain important information on how to apply for admission as
an undergraduate Midwifery Student and useful information which will be of help to you
later in the year should you have any queries.

Please ensure that you have signed the declaration on the application form and the
consent to a criminal records check.

Failure to sign these forms will result in your application being rejected and the form
will be returned to you.




                                                                                          14
           GUIDANCE NOTES FOR THE COMPLETION OF APPLICATION FORM

                      BSc (Hons) in Midwifery Studies 2012-2013

Complete all sections of the application form in BLOCK CAPITALS (typewritten or in black ink).
Failure to complete a section of the application form, or failure to legibly complete the form, may
mean your application will not be processed. You may download the form and complete it using
a Microsoft Word processing package, but all signatures must be handwritten originals.

Note: It is the responsibility of the applicant to ensure that the completed application
form and references arrive by the closing date: 4pm on Friday 6th January 2012.
Incorrect postage will not be accepted as a reason for late arrival.

SECTION 1:                      PERSONAL DETAILS

Please ensure that your first name(s) are given in full and as stated on your Birth Certificate.

The correspondence address that you provide on your application form will be the address we
will use to communicate with you. If your address changes during the application process, you
must notify the School of Nursing and Midwifery Registry Office in writing immediately.
The School will not be responsible for your failure to communicate this information.

The School of Nursing and Midwifery will endeavour to take account of your availability for interview,
however it is under no obligation to do so.

SECTIONS 2, 3 AND 4:            INSTITUTES ATTENDED, EDUCATIONAL AND
                                PROFESSIONAL QUALIFICATIONS

Please list the details of all of your educational qualifications in full. If you have been educated
outside the UK or Republic of Ireland, please enclose photocopies (and translation into English
if applicable) of your educational certificates. Please do not send originals.

You are required to notify the School of Nursing and Midwifery if you have ever previously
commenced a nursing or midwifery programme. Please give full details of the institution,
programme, date of leaving, your reasons for leaving and, if applicable, your Professional
Identification Number (PIN).

If you are invited to attend an interview for the BSc (Hons) Degree in Midwifery Studies, you
will be required to present all relevant original documentation and a valid form of
photographic ID before the interview can commence. The School of Nursing and Midwifery
will write to selected candidates with further details prior to the scheduled interview date.

SECTION 5:                      EMPLOYMENT HISTORY

If you have been employed, please give details of your employment history, beginning with your
most recent position, indicating whether the position was full or part-time. Please specify exact
dates and ensure that you cover all periods of employment and unemployment with no gaps.
Please also provide details of the minimum period of notice required by your employer.

SECTION 6:                      REFEREES

Please provide the names and addresses of two persons, who have agreed to act as referees
on your behalf. These persons must not be relatives, friends or neighbours and their
knowledge of you must have been within the last 2 years. They should be people who know you
in an academic, and where relevant, a working capacity. Your first referee must be someone
who can provide an academic reference such as School Director or University Head of
Department. Your second referee should be your current or most recent employer.


                                                                                                         15
It is your responsibility to ensure that references are received by 4pm on Friday 6th
January 2012. The School reserves the right to make direct contact with your referees.

SECTION 7:                     ADDITIONAL INFORMATION

Please give any further information which is relevant to your application, in particular your reasons for
wishing to join the programme, what benefits you expect to gain and the attributes and abilities you
have relevant to the programme for which you are applying, also please give brief details of your spare
time activities and any membership of clubs and societies. You must use only the space provided
(max 300 words). Please do not submit extra sheets.


SECTION 8:                     DECLARATION AND SIGNATURE OF APPLICANT

Please read the declaration carefully before signing and dating your application form. This
section of the application form MUST be completed and signed. Failure to complete this section
may result in non-acceptance of your application.

APPENDIX 1:                    CRIMINAL RECORDS CHECK

IMPORTANT INFORMATION ABOUT, AND CONSENT TO, THE ACCESS NI ENHANCED
DISCLOSURE CHECK OF APPLICANTS FOR POSTS INVOLVING WORK WITH CHILDREN
AND VULNERABLE ADULTS.

The programme you have applied for involves working with children and/or vulnerable adults. As
part of the selection process, the School of Nursing and Midwifery is required to ensure that its
students are of good character. Therefore the School conducts criminal history checks on
anyone who is made an offer for entry onto the programme. This includes general criminal
activity as well as suitability for working with children and vulnerable adults under the
Safeguarding Vulnerable Groups Act 2006 and Northern Ireland Order 2007.

Admission to healthcare courses is subject to The Rehabilitation of Offenders Act (1974)
Section 4 (2) (Exemption) Order 1975; The Rehabilitation of Offenders NI Order 1978 and
DHSS Circular HV (88) 0 guidelines regarding child protection and police checks, the
Safeguarding Vulnerable Groups Act 2006 and Northern Ireland Order (2007). An Access NI
Enhanced Disclosure check is made to ensure that people who might be a risk to children and
vulnerable adults are excluded from the programme.

You MUST complete and return the Criminal Records Form with your application. Your
application will not be considered without it. If you suspect that you have a criminal record,
no matter how insignificant or long ago, you should contact the Criminal Records Office (NI)
within Police Headquarters to establish the information held against your name. No criminal
record is ever spent as regards completing this section of the application form.
Everything that appears against your name on your criminal record must be included. If you do
not include any information, which is subsequently disclosed via criminal records checking, any
offer of a place may be withdrawn.

If you are being supported by an NHS Trust in your application it may be possible for the
Trust to provide an Enhanced Disclosure Certificate on your behalf, if they are holding one that
is less than 6 months old; otherwise you will need to ask your employer to carry out this check.

When providing the School of Nursing and Midwifery with this information, you MUST tell us if
you have ever been convicted of a criminal offence, cautioned by the police, or bound over, or
anything else that appears on your criminal record, or if you have any prosecutions pending.
You must include all offences, even minor matters such as motoring offences, and ‘spent’
convictions, including things that happened a long time ago.


                                                                                                       16
Some criminal activity is incompatible with a career in midwifery. Other activity is considered
insignificant, and while it must be declared on this form, it is unlikely to affect your application to
the programme. In between these two extremes is a wide range of criminal activity (for example
assault, disorderly behaviour and theft) that will require you to have an additional interview
before a decision can be made. The outcome of this interview may result in your application
being withdrawn. In some situations you may be permitted to reapply to the programme after a
specified period of time. During this period of time you will be expected to build up a ‘good
character’ history and be able to provide references from current/recent employers.

You MUST also inform the School of Nursing and Midwifery if you are currently, or have ever been,
subject to an investigation and/or disciplinary proceeding by a healthcare-related employer, agency or
regulatory body, irrespective of the outcome.

You MUST read the information contained within this section and provide the details requested, before
signing and dating this section of the form. A payment of £30* is required by Access NI to carry out
your Enhanced Disclosure check. It is possible that in future you will have to register with an
organisation called the Independent Safeguarding Authority. Until the review of the Scheme is
complete Enhanced Disclosure Certificates will be requested for all those in regulated activity. The
report will indicate whether you have a criminal record, or whether the DHSSPS or HSC holds any
other information about you, which might have a bearing on your suitability for entrance to a nursing
programme. Any information received will be treated confidentially and in compliance with ANI’s Code
of Practice and will be discussed with you before a final decision is made on your suitability to enter the
programme. You should note that Placement providers require confirmation of whether your criminal
history check is clear or not. In some situations they may require access to the specific detail on your
Enhanced Disclosure Certificate (criminal history check) before allowing you to commence your
placement. To avoid any delay with providing this information to your placement provider, and
subsequently delaying the start of your placement, you should sign and return the attached Criminal
History Consent Form.

* Please note that this cost may be subject to change. If you are made an offer to join the
programme, you will receive details of how to make your payment.

If you have been resident in the UK for less than 5 years you will also be required to provide
evidence of good character. Further information and guidance can be found at
www.crb.homeoffice.gov.uk

Please Note: It is no defence, should a criminal record be discovered by the School of
Nursing and Midwifery, to claim that you were unaware of your criminal record or its
significance when completing this form. An applicant who attracts a criminal record
after applying and before the date of admission to the University must inform the School
of Nursing and Midwifery Registry Office in writing without delay. If an applicant has
failed to disclose the information required, they may have their application, or any offer,
withdrawn.

APPENDIX 2:                      REFERENCE FORMS

Please insert your name and correspondence address in full in the space provided and forward
the reference form to your first and second referees (i.e. the persons named in Section 7 of the
application form). Please ask your referees to return completed references to the School of
Nursing and Midwifery by the closing date to the address provided. It is your responsibility to
ensure that references are received by 4pm on Friday 6th January 2012. The School
reserves the right to make direct contact with your referees.


APPENDIX 3:                      CLINICAL AREA



                                                                                                          17
Please complete the Clinical Preference Form and return it with your application form. The
University reserves the right to make the final allocation.




                                                                                             18

								
To top